Norwegian University of Science and Technology

Spring 2013

Expert in Team Work (Childhood Village)

Project report

Childhood obesity on increase; attitudes toward physical activities among children

By: The golden age group (Furqan, Fridah, Tadiwos, Tina Louise, Berit and Christina)

Supervisor: Firouz Gaini

18.01.2013

1. Introduction

1.1. Background

Obesity is defined by the World Health Organization (WHO) as “abnormal or excessive fat

accumulation with a body mass index (BMI) greater than or equal to 30” (WHO, Obesity and

overweight Fact sheet N°311, 2012). It is becoming a major global as well as national

(Norway) issue not only among adults but also among children escalating the concern about

children’s health and well-being (Flegal et al., 2006). Childhood obesity is more difficult to

define as children are constantly changing weight due to normal growth and development.

Thus, the assessing healthy weight requires comparing the BMI of a child with the BMI of

other children of the same age, gender, ethnic origin and social class (Flegal et al., 2006;

Aycan, 2009). Conventionally, childhood obesity is defined as the 95th percentile or greater of

BMI for age (CDC Growth Charts, 2010).

Obesity is an increasing health problem worldwide, and in our study we are focusing on

children. Looking at Europe, the Scandinavian countries have a lower prevalence of obesity

compared to the Mediterranean countries, but the prevalence is on the increase also here

(Dehghan et al., 2005). A study carried out at the University of Bergen (2010), concluded

that 14% of Norwegian children between the ages of 2 and 19 were obese (Juliusson et al.,

2010).

Obesity has many medical and non-medical adverse consequences, both at the individual

level as well as in the society as a whole. The medical consequences of childhood obesity

include cardiovascular complications (such as hypertension, atherosclerosis, dyslipidaemia

and heart disease), metabolic disorders (such as insulin resistance, the metabolic syndrome

and diabetes type 2), pulmonary complications (such as asthma and obstructive sleep apnea),

gastrointestinal disorders (such as liver disease and gastroesophageal reflux disease), and

skeletal abnormalities (such as hip problem and abnormal tibia growth). It is also linked to

psychosocial problems such as depression, poor body image, and low self-esteem and

confidence (Daniels, 2006; Lee, 2009). Obesity also affects the whole society as it increases

the economical expenditures for obesity related medical treatments, and hence the

expenditures of the society in general (Finkelstein et al., 2005; Covic et al., 2007).

There are many factors causing obesity, including lifestyle choices such as diet, cultural

environment, behavioral and social factors, level of physical activity etc. There can also be

genetic causes of obesity, though this is rare (Ebbeling et al., 2002; Dehghan et al., 2005).

Various studies across Europe have shown that physical activity greatly reduces the incidence

of obesity. Other studies have shown that several individual factors, including attitude, affect

children’s participation in physical activity (Cavill, 2006:13). In social studies of children,

they are seen as active participants in society, and children should be viewed as competent

individuals able to make decisions about their own life when they are given the necessary

information. This is called agency (Ibid, 113).

1.2. Why “Children’s attitudes towards physical activities?”

The trend around the globe is that obesity among children is increasing, and Norway is no

exception. There are different reasons for this, related to especially diet and level of physical

activity. We wanted to check out the children’s relation to physical activity. Does the increase

in childhood obesity mean children are less physically active? Or are they becoming obese

because they are less physically active? Or do they/do they not like to participate in physical

activity? Or do they want do to more physical activity but they are not able to? Are children

spending so much time on the computer? These curiosities and the fact that the trend of

childhood obesity is escalating prompted us to think of and assess children’s attitudes

towards physical activities by asking them about their reasons for being or not being in

physical activity. Assessing the attitude is critical as we can rule out the real motives of

children’s towards physical activity.

1.3. Significance of the project

The result of this project can provide information about the children’s attitude towards

physical activity filling the knowledge gap in this field. This is very instrumental to design

new policies and strategies that increase the participation of children in physical activities at

community, society, federation and country level. The study might also come up with

justification for the need to consider children as competent individuals and active member of

the society that necessitates the active involvement of children in decisions making,

maximizing their roles in their own health and other aspects of life. The need to consider

children’s attitude will also be a new room to be explored by Norwegian Federation of Sport

(NIF) and by Center of Overweight and obesity St. Olav Hospital (RSSO) for effective

implementation children’s sport right and developing child obesity treatment and

interventions, respectively.

2. Methods

2.1. Participants

Data collection of this study involved 34 children (16 boys and 18 girls) in 5 th grade, all aged

10 years.

2.2. Quantitative and Qualitative research methods

Any research is essentially communication from the informants or participants (Svennevig,

2001). Selection of particular methods to use and to facilitate this communication is in

influenced by a lot of different factors, one of which is time. In this study, only three/four

weeks were available to both execute the research and write a report, In view of the limited

time and the nature of the study on attitudes of children towards physical activity, a mixed

method procedure, using both qualitative and quantitative methods within the same study was

used. This could be seen as a natural emergence when mixing social sciences with human

sciences (Creswell, 2003).

2.2.1. Questionnaire

To collect quantitative data, a questionnaire was used. The answers from this questionnaire

provide objective data as a result from empirical measurements (Creswell, 2003). The

questionnaire covered various aspects of everyday life starting with school in the morning to

various activities after school, in their leisure time. This makes it easier to follow the

sequence pattern enabling the children to easily recall what they are involved in. This gave

opportunity for the research to get a wide perspective of children on various activities in the

limited time available. However, misunderstandings can possibly arise both in conversation

and in text, but mostly in the latter (Svennevig, 2001). The questions used were at level of the

participants (10 years old) knowledge, and also make the content of the questions customized

for achieving this goal (confused about the last part of this sentence). To ensure validity,

there was need to triangulate data by use of a second instrument, the drawings.

2.2.2. Drawings

The other factor to consider in the selection of methods has to do with the target group or

research participants. The United Nations Convention on the Rights of the Child (UNCRC)

advocates for the rights of children to express themselves and participate in decision –making

on matters that affect them (Birbeck and Drummond, 2007). Further, Article 12 states that

government nations;

Shall assure to the child who is capable of forming his or her own views the right to

express those views freely in all matters affecting the child, the views of the child being

given due weight in accordance with the age and maturity of the child (UN,1990).

Moreover, adults who make decisions on behalf of the children should ensure that the best

interest of the child is upheld, by providing the care and support that the children require.

Yet, for a long time, very few children have found their voices in research due to researchers’

concerns about children’s competence, power of communication and cognitive abilities. This

study uses participant friendly methods, “giving voice to the voiceless.” Birbeck and

Drummond (2007) further observed that, “if one engages children appropriately in

information gathering process, there is no reason why their perceptions and thoughts should

not be regarded as competent.” This appropriateness implies moving from adult-centered

view of children as incompetent and look at them as knowledgeable on matters that affect

them. It also entails using methodologies which support their intellectual and social abilities.

Thompson (2008) notes that there has been a “visual turn” in the social sciences increasing

the visual research, sometimes called image – based research. One of the reasons for this is

that visual sociology offers different ways to elicit the experiences, opinions and perspectives

of children. One such methodology is Clark’s Mosaic approach. It recognises Mallaguzzi’s

principle of “The Hundred Languages of Children” in which they can express themselves.

She points out that it is,

a strength-based framework for viewing young children as competent, active, meaning

makers and explorers of their environment. ..The Mosaic approach brings together a

range of methods for listening to young children’s perspectives about their lives.

Observation sits alongside participatory tools. It seeks to understand how children ‘see’

the world in order to understand their actions. (Clark, 2005:29).

The participatory tool used in this pilot project is affording our informants, who are 10 years

old to express their activity preference by making a drawing in a task called ‘My favourite

activity’ and giving a reason’. In relation to the project topic on the children’s attitudes

towards physical activity, such an activity treats them as experts on the subject matter and

opens the way for various perspectives of children on various activities. But it still affords

researchers the opportunity to gather the children’s views in relation to physical activity.

The reason for their choice of activity is sort (?) and compared to their response in the

questionnaire on a similar section for the sake of validity. This is particularly so because of

limitations of time and other material resources to allow for triangulation through other

research methods like interviews to discuss the drawings. Moreover, different methods are

appropriate for different age groups. Johnson (2008) observed that younger children may be

interested in drawing and playing games. Furthermore, Punch (2002) noted that using

drawings as a research method can be creative fun and encourages children to be more active

in the research with the added advantage of more control over their form of expression.

The visual research is also important in that the drawings communicate in a different way

than words. Children are themselves interested in drawings and images, and therefore, visual

research matters to researchers interested in the lives and experiences of children. Visual

research methods may elicit different responses than methods which are primarily speech and

written word – based. The process of producing visual data may mean more to the children

than just the research and its outcome, as it is something they enjoy, are competent at, and a

different way of expressing themselves (Thompson, 2008).

As the drawing was done before the questionnaire was administered, it gave the children a

relaxed environment but still prepared them for the more challenging and involving task of

answering the questionnaire. In combination with the drawing, it broadened the view and

offers opportunity to triangulate the children’s attitudes. As such, use of both qualitative and

quantitative methods facilitated proper analysis of results to the question at hand. All in all,

this project respected the views of the children and affords them chance to express

themselves in a relaxed setting, away from the influence of authoritative parents and teachers

as recommended by Birbeck and Drummond (2007):

Children’s voices can be heard in research by understanding that children can

participate in meaningful ways if the research environment is one in which they feel safe,

supported and valued. The research environment must be seen through the child’s eye.

2.3. Ethical considerations

2.3.1. Informed Consent

When working with children as research participants, it is very important to remember the

ethics of research. Because children are below legal age, their parents or legal guardians need

to consent for them if they are to participate in research of some kind. In this research, the

school was informed through both written and verbal communication, and in turn

communicated to the parents through E-mails. Apart from the consent of the legal guardians,

the participants were informed that they were not obliged to participate. The information

sheet given to the guardians also said that the survey was completely anonymous, and it

included some information about us, Expert in Team (EiT) and our project. The background

for this was NSD’s (Norsk samfunnsvitenskapelig database – Personvernombud for

forskning) guidelines for what to include in a consent form1.

2.3.2. Confidentiality, Privacy and Rapport

For this project no sensitive information like name, address, or other information was

collected to identify the participants. The participants were assured that the information

collected was purely for the study. Time limitations did not allow for establishment of a good

rapport with the participants and this therefore may have influence on the validity and

reliability of the findings as children may say what the researcher wants to hear (Punch,

2002).

2.4. Reciprocity

The question of ‘giving back’ or doing something about the situation is always a dilemma in

academic research. It remains in the hands of the cooperating partners to use the information

gathered to better the welfare of the children in relation to implementation of programs to

promote physical activity and reduce incidences of obesity.

2.5. Power Differentials and Research Context

There are always unequal power relations between adults and children. The study attempted

to minimise such influence by using participant friendly method of freestyle drawing and thus

reduced undue contact with the participants. Much as their teachers were not present in the

room, the research context of the school however, might have influenced the children to give

1 http://www.nsd.uib.no/personvern/meldeskjema [Read January 21st 2013]

the ‘correct’ answer (Punch, 2002) as they are always used to in a school set-up, instead of

their actual perspective. (but the teacher was present?)

3. Theories

3.1. Medical background of obesity

3.1.1. Definition of childhood obesity

In short obesity, represents a condition where a pathological excess of body fat is present in

an individual (Aycan, 2009).

practically either BMI or body fat percentages is used to define and to track obesity (Aycan,

2009). BMI is a measure of weight-for-height calculated by dividing person's weight in

kilograms by the square of his height in meters. Although it is imprecise, BMI is widely used

especially in defining cutoff for adulthood obesity as it is easy and correlate sufficiently with

direct measurements. Conventionally, a BMI value between 18.5-25 is normal while BMI

value greater than or equal to 25 and 30 is an indication overweight and obesity, respectively

(Aycan, 2009, WHO, 2012).

BMI based body weight classification is crucial as it well correlates the risk for medical

complications of obese patients, which increase at BMI levels above 25. A BMI greater than

27 is associated with incidence of hypertension, hypercholesterolemia, and diabetes mellitus

while a BMI less than 25 is associated with increased social and psychological complications

of weight gain (Aycan, 2009). Body fat percentages measure of weight, height, and the

amount of fat on different body parts to estimate body fat percentages. In general, Women

with more than 32% body fat and men more than 25% body fat are considered obese (Health

people library project, 2006).

Obesity is not just a problem for adults, as teenagers, adolescents, and even pre-schoolers are

beginning to show signs of obesity in greater and greater numbers. This might explain why

obesity is becoming a major global as well as national (Norway) issue among children,

escalating the concern about children’s health and well-being (Flegal et al., 2006).

In childhood, there is not a universal definition of obesity and overweight as children are

constantly changing weight due to normal growth characterized by a sharp increase during

infancy, peaking at about 9 months and decreasing thereafter until about 6 years before rising

up. Thus, the assessing healthy weight requires comparing the BMI of a child with the BMI

of other children of the same age, gender, ethnic origin and social class (Flegal et al., 2006;

Aycan, 2009).

Unlike adulthood obesity that is defined based on fixed BMI values related to health risk,

childhood obesity is defined using percentiles of BMI-for-age in a specified reference

population as there are no clear risk-related values of BMI (Flegal et al., 2006). In line with

Centers for Disease Control (CDC) BMI charts (table 1), in some countries childhood obesity

is defined as the 95th percentile or greater of BMI for age, and those with BMI between the

85th and 94th percentiles are considered as overweight (CDC Growth Chart, 2010; Speiser et

al., 2005).

Table1: CDC Children BMI Classification for Age Percentile [Age 2-19]

Category Age Percentile

Underweight ≤ 5th percentile

Healthy Weight 5th to the 85th percentile

Overweight 85th to the 95th percentile

Obese ≥ 95th percentile

Alternatively, ideal weight for height percentage can be used to describe childhood obesity.

Accordingly, a weights being greater than 120% and 140% of ideal weight indicate obesity

and sever obesity, respectively (Mei et al., 2002).

3.1.2. Epidemiology of childhood obesity

Obesity is becoming a worldwide epidemic public health problem with poorly understood

syndromes affecting both children and adults regardless of gender and ethnic/racial group

(Aycan, 2009). United States has the highest rate of prevalence of childhood overweight and

obesity as compare to other countries (National Obesity Observatory, 2010).

Among European countries, the Scandinavian countries have lower rate of childhood obesity

prevalence as compare to Mediterranean countries, but it is increasing also here (Dehghan et

al., 2005). Approximately, 30% of Europeans countries are affected by obesity and its

development is leveling off (Juliusson et al., 2010). Similarly, the obesity trend in children is

rising (Aycan, 2009). The prevalence rate of obesity is at highest in the developed countries

but it also increasing in developing countries, being highest in Middle East, Central and

Eastern Europe (Dehghan et al., 2005).

Norwegian children’s prevalence rate of overweight and obesity is similar to those reported

in Northern and western European countries but lower than those reported in United States,

United Kingdom and southern European countries (Aycan, 2009, Juliusson et al., 2010).

An epidemiological study conducted by University of Bergen (Norway) to estimate the

prevalence of childhood overweight and obesity and to identify the socio-demographic risk

factors involved showed that 14 % prevalence of obesity. This study also identifiedsocio-

demographic factors such as age, sex, ethnic origin, family size, educational and occupational

status of parents as factors that affect the prevalence (Juliusson et al., 2010).

3.1.3. Consequences of obesity

Since childhood obesity is a multisystem disease, a disease involving various systems, it is

associated with different short-term and long-term consequences that can be categorized into

medical and non-medical complications (Ebbeling et al., 2002; Lee, 2009).

3.1.3.1. Medical Consequences

The medical consequences of childhood obesity can be broadly classified into cardiovascular

such as hypertension, atherosclerosis, dyslipidaemia, heart disease (such as left ventricular

hypertrophy) and stroke), metabolic (such as insulin resistance, the metabolic syndrome and

diabetes type 2), pulmonary complications (such as asthma and obstructive sleep apnea),

gastrointestinal disorders (such as liver disease and gastroesophageal reflux disease), skeletal

abnormalities (such as hip problem and abnormal tibia growth) and others medical

complications (such as polycystic ovary syndrome, pseudotumor cerebri, gallstones, arthritis,

gout and cancer) (Ebbeling et al., 2002; Daniels, 2006; Health people library project, 2006;

Lee, 2009). These complications have been widely studied in obese adults as their

development takes years to be manifested in obese children (Aycan, 2009).

Hypertension, or high blood pressure, is one of the common complications of obesity both in

adults and children. Several studies showed that compared to non-obese children, obese

children are at higher risk for hypertension and the risk increases across the entire range of

BMI values peaking at or above the 90th percentile (Daniels, 2006; Lee, 2009). Changes in

multiple physiological processes such as insulin resistance, over-activity of the sympathetic

nervous system, activation of the renin-angiotensin system leading to increased renal sodium

re-absorption and reduced natriuresis (excretion of sodium in the ureine), and abnormalities

in vascular structure and function were suggested to be contributor of obesity-associated

hypertension in children (Lee, 2009).

Childhood obesity is also associated with insulin resistance, (Daniels, 2006). Insulin

resistance in turn leads to glucose intolerance, hypertension and dyslipidemia as evidenced by

an increase in the prevalence of type 2 diabetes mellitus in children and adolescents with

increase of childhood obesity prevalence (Lee, 2009).

It was reported that children with a BMI above the 85th percentile had an increased risk of

asthma regardless of their age, sex, ethnicity, socioeconomic status, and exposure to tobacco

smoke. However, it is not clear whether obesity causes asthma or the other way round. An

epidemiological study found that one-third of young severely overweight patients had

symptoms associated with obstructive sleep apnea and 5 percent had severe obstructive sleep

apnea. Obstructive sleep apnea, an abnormal collapse of the airway during sleep, results in

disrupted sleep patterns. Sleep disruption can lead to excessive daytime sleepiness, decreased

physical activity and school performance, as well as increased risk of further obesity. This in

turn may lead to long term adverse cardiovascular consequences, learning disabilities, and

memory defects (Daniels, 2006).

Growing data from cohort studies showed that non-alcoholic fatty liver disease as a metabolic

consequence of obesity and a common cause of chronic liver disease in obese children (Lee,

2009). Fat starts to deposit in the liver in response to obesity and initially the deposits are

relatively innocuous. However, the deposits later lead to steatohepatitis, which can then

progress to fibrosis, cirrhosis, and even to end-stage liver disease and liver failure, ultimately

requiring a liver transplant. Insulin resistance, hyperlipidemia, and increased oxidative stress

are implicated in the pathogenesis (Daniels, 2006).

The most common childhood obesity related skeletal abnormalities (orthopedic problems)

include hip problems (slipped capital femoral epiphysis), and abnormal growth of the tibia

(Tibia vara, or Blount disease). Some complications of obesity are physical, the effect of

excess body weight, rather than metabolic, or the effect of increased adipose tissue (Daniels,

2006).

The most prevalent complications of obesity are psychological consequences, which involve

psychological health and the ability to relate to family members and peers. These include

depression, poor body image, low self-esteem and confidence, reduced health-related

physical quality of life in , emotional and social aspects (Daniels, 2006; Lee, 2009).

Depression is the most widely studied psychological consequence of childhood obesity.

However, it is not clear whether obesity causes depression or the other way round as

depression itself is often associated with abnormal patterns of eating and physical activity

that could result in future obesity. obesity may also result in psychosocial problems that can

produce depression (Daniel, 2009).

Childhood obesity is one of the contributors for discrimination and stigmatization of obese

children in school and it might partly explain why obese children have difficulties with peer

relationships and have few friends (Lee, 2009; Daniel, 2009). An important psychosocial

issue for overweight children and adolescents is quality of life. This was confirmed by a

study that reported a significantly lower health-related quality of life and five times risk of

impaired quality of life in obese children and adolescents than their normal-weight

counterparts. obese children and adolescents with obstructive sleep apnea reported even

lower quality of life, maybe because of increased daytime sleepiness (Daniel, 2009).

3.1.3.2. Non-medical complications

Non-medical complications of childhood obesity equally require attention and contribute in

tackling of obesity. The main non-medical complications are social consequences that result

from psychological complications and economical expenditures. The former includes all

those psychological factors that against obese child consequently leading to less education,

lower incomes and higher poverty rates in the society. The economical expenditures

encompass obesity-related medical treatments and expenditures that significantly increase the

overall expenditures of society (Finkelstein et al., 2005; Covic et al., 2007; Lee, 2009).

3.1.4. Causes of obesity

Normally bodyweight is regulated by maintaining the balance between energy intake and

energy expenditure. There are several factors that disrupt this balance either by increasing

energy intake or reducing energy expenditure leading to obesity. Development of labor

saving device as a result of advancement in technology is the principal cause of reduced

energy expenditures. In addition, other factors like genetic, behavioral and social factors play

a role in the pathogenesis of childhood obesity (Ebbeling et al., 2002; Dehghan et al., 2005).

Genetic factors predispose a child to an obesity-conducive environment. Deficiency in certain

genes can directly or indirectly increases the risk factor for developing obesity. For instance,

leptin gene is important for expression of leptin, a peptide hormone that plays a key role in

maintaining of energy intake and energy expenditure balance. Any abnormality in leptin

function is associated with a higher risk of childhood obesity, as it can affect appetite and

metabolism (Dobson, 2003). Studies confirmed that the derangements in other genes such as

hypothyroidism and growth hormone deficiency may indirectly lead to childhood obesity

(Dehghan et al., 2005).

More importantly childhood obesity is affected by personal lifestyle choices, cultural

environment, behavioral and social factors including bad eating habit, sedentary life style

(lack of exercise) and family factors (Ebbeling et al., 2002; Health people library project,

2006).

Natural and healthy foods are best for the human body. For healthy physiology, foods should

contain proteins, carbohydrates and fats. Proteins are important for growth, building and

maintaining body's organs, tissues, and muscles, and for facilitation of digestion (Health

people library project, 2006). Carbohydrates rich diets, which normally provide energy, such

as bread, ready-to-eat cereals, potatoes, soft drinks, cakes, and biscuits increase blood glucose

level and control appetite. Frequent consumption of these foods induces hormonal cascades

that stimulate hunger and cause overeating, which in turn increase risk for central adiposity,

cardiovascular disease and type 2 diabetes (Ebbeling et al., 2002). Beverages with high

glycaemic index, particularly fruit and soft drinks, are responsible for increased energy intake

and excessive weight gain because incomplete compensation for calories consumed in liquid

form. By contrast, milk, a low glycaemic index beverage, seems to protect overweight young

adults from becoming obese (Ebbeling et al., 2002; Finkelstein et al., 2005). Fats help

growth, to insulate the body, to create some hormones, to absorb some vitamins, and to have

healthy hair, skin, and hearts (Health people library project, 2006).

There is no a strong and direct relationship between prevalence of childhood obesity and fat

intake though excess consumption of fats. This necessitates the consideration of other factors

such as the type of fat, as saturated fats are more risky than unsaturated ones (Ebbeling et al.,

2002; Dehghan et al., 2005). Despite lack of supporting evidences, increased calories

consumption significantly contribute to the ascending trend of childhood obesity as it might

affect satiety and food consumption (Ebbeling et al., 2002; Dehghan et al., 2005; Finkelstein

et al., 2005). During eating more calories than the body can use up, the calories will be

stored and converted into fat cells increasing risk for overweight or obesity (Health people

library project, 2006).

Sedentary lifestyle or lack of physical activity is strongly associated with increased risk of

childhood obesity as evidenced by epidemiological data that show increased prevalence of

obesity in children with sedentary behaviors like watching television and playing computer

games (Health people library project, 2006; Ebbeling et al., 2002; Dehghan et al., 2005).

Watching television promotes weight gain by reducing physical activity and increasing

energy intake. Increased food intake and advertisement of unhealthy foods on television are

the main contributors of increased energy intake while viewing television (Ebbeling et al.,

2002).

3.2. Physical activity

In today’s technological advances, simple tasks are being mechanised and children are

exposed to sedentary leisure activities before the screen, thereby increasing inactivity in a lot

of them. This has led to the increase in non-communicable diseases including overweight

and obesity among children. A study notes “during the last 3 decades, the prevalence of

obesity has tripled among persons aged 6-19 years.” (MMWR, 2011). Cavill et al (2006)

noted that physical inactivity is estimated to account for nearly 600,000 deaths per year in

Europe. The significance of physical activity on the general health of the people including

children is immense. It is used as a preventive measure and slowing down the progression

rate of chronic diseases. These diseases are heart disease, stroke, diabetes and obesity among

others. In various studies conducted at different times across Europe, it was shown that

physical activity greatly reduces the incidence of obesity and other non-communicable

diseases. Erlichman and others (2002) reported that “The alarming rise in childhood obesity

and its role in promoting cardiovascular disease in adulthood noted an inverse relationship

between physical activity and body fat.” Many other studies indicate the same.

Over the past half-century scientific data have continued to accumulate indicating

that being physically inactive or unfit has major negative health consequences

throughout the lifespan and is an important component of a comprehensive approach

to chronic disease prevention and health promotion ( Haskell et al., 2009).

According to WHO (2010), reporting the physical fitness and health status of children and

youth, there are substantially enhanced by frequent physical activity. The role of physical

activity in management of weight and obesity can therefore not be overemphasised. It is

important therefore that the attitudes of the children towards physical activity are assessed

especially in the current technological age, where lack of time or simply no interest at all are

likely to influence these feelings.

Physical activity is defined as “any force exerted by skeletal muscles that results in energy

expenditure above resting level” (Cavill et al, 2006:2). Such activities are basically activities

that children can be engaged in such as dancing, skipping, brisk walking, jump rope,

swimming, cycling, playing football and other games. Physical activity is categorised at

different levels depending on the intensity and these are; low, moderate and vigorous activity.

Intensity has to do with the amount of effort made by an individual in the physical activity.

Low intensity means that very little energy above the resting level is expended. Moderate

intensity activity is that which increases the heartbeat, makes the body warm, with one

becoming slightly breathless. The third category of physical activity is the vigorous one

which is mainly sweaty and leaves persons breathless (Ibid, 2006).

Measurement of physical activity encompasses type of activity, time spent on it, frequency

(how often) as well as intensity (how hard) (WHO, 2010:18). Our focus for the study is the

moderate form of physical activity, and the extent to which the children are involved in this.

By considering their attitudes towards such physical activity, it is easy to ascertain the factors

leading to the increase in childhood obesity cases. Moreover, WHO recommends that

individuals must be engaged in adequate levels of physical activity throughout their lives,

including children and young people who should achieve at least a total of 60 minutes of

moderate-intensity physical activity in most days of the week (Ibid, 2006).

To get the full health benefits of physical activity, the children’s attitudes must be taken into

perspective and design approaches that maximise these benefits. In the process of carrying

out these physical activities, it is important that they are conducted in a fun manner, to keep

the interest of the children high. Apart from the immense physical health benefits that

physical activity offers, children also acquire social skills, self-positive image and a high self-

esteem as well as academic achievement and general high performance (Ibid, 2006; Haskell,

2009).

There are various levels of factors that influence the attitudes towards physical activities both

in the adults and the children. These occur at individual micro and macro- levels as outlined

by the European and World Health Organisation (Cavill, 2006). The macro-level factors are

mainly socio-economic conditions including free-time, fear of traffic, security reasons and

social status to discourage engaging in physical activities. One example can be a child

avoiding walking to school when the parents own a car as it is not expected by society. At the

next level is the micro- level, including urbanisation, place of residence and proximity of

facilities. There are fewer manual jobs as most simple tasks like washing and climbing stairs

have been replaced by washing machines and escalators respectively. As such, there is very

little activity that the children are routinely involved in whether they have a positive or

negative attitude towards physical activity. WHO-Europe suggested that our lives should

integrate activity in our daily routines and not an option in order to embrace active living

(Ibid, 2006). The last factor, and of particular interest to our study has to do with the

individual. The major ones that play against involvement in physical activity are lack of time,

perceived benefits, social support, personal safety and being too exhausted among others.

3.3. Childhood theories

The well-being of children is a concern for many from individual level and family to that of

national governments to international institutions. One such area of concern is the children’s

health for now and for the future, especially with the rise in obesity. A study conducted in

Canada noted:

A major concern regarding childhood obesity is that obese children tend to become

obese adults, facing an increased risk of diabetes, heart disease, orthopaedic

problems and many other chronic diseases. Increasingly, paediatricians are seeing a

rise in incidences of childhood hyperlipidemia, hypertension and diabetes (Santrock,

2004).

Norway is no exception. Juliusson and his colleagues (2010) noted that overall obesity

prevalence of primary school children in Norway is of concern. This therefore calls for effort

of not only the adults, but the children themselves to be involved and take an active role and

make a difference in matters that affect them. In the social studies of children, childhood is no

longer seen as just an early part of the life-course, a preparation for the future, but a life that

has to be lived meaningfully at the present moment. It considers children as active

participants in society who are capable of influencing or shaping as well as being shaped by

the occurrences around them (James, 2009). In relation to the issue of obesity, children must

be viewed as competent individuals who can take charge of their own health (just like adults)

when provided with the necessary information concerning their development, and physical

health including lifestyles that can be adopted in order to maintain it.

Santrock (2004) defined development as the “pattern of biological, cognitive and socio-

emotional changes that begin at conception and continues through the lifespan”. The

biological encompasses changes that occur in the size of the body, cognitive, covers the

child’s thinking and intelligence while the socio-emotional involves the child’s relationship

with other people and changes in personality. In the biological development, Santrock (2004)

noted that as the children get into elementary school years, they gain greater control of their

bodies, and physical action is essential to refine their developing skills. No child develops

exactly in the same way as the other, hence their competence in taking an active role in

matters that affect them, does not necessarily have to do with the chronological age but the

social age as proposed by Clark-Kazak (2009). The social age is more realistic as the

experiences of children vary widely in relation to the society they are found in. In the social

age notion, “Expectations hinge around when children are seen as having achieved

understanding, or competence appropriate to that situation” (2003:90). As stated in the

National Framework Plan 1996, outdoor activities (“friluftslivet”) should be advocated

among Norwegian for good overall development of the children. Writing on such practices in

the Norwegian culture, Nilsen (2008), pointed out that the top agenda of the government is

enhancing children and young people’s opportunities to develop physically, socially and

mentally through walking and playing about in, and experiencing nature.

Based on their attitudes, especially in the technological age of spending time before the

‘screen’ it is essential to collect information about their thoughts and feelings and how these

views in a way, can be used to influence the fight against obesity and make appropriate

interventions. Although outdoor activity is basically part of the daily routine of an average

Norwegian child from day care through elementary school and even at home, there has been

concern shown in what Nilsen terms the ‘discourse of worry’. She refers to Tingstad (2003)

and Buckingham & Bragg (2004) who raised concern that many (post)modern childhoods are

associated with many negative influences as participants in the global child market and the

growth in sedentary leisure pursuits, threatening the happy, healthy and outdoor Norwegian

childhood. With such modern influences therefore, it becomes essential to hear from the

children. At this point, they have enough experience and exposure to these activities and

therefore have their own views which would help towards reducing the prevalence of the

scourge. When children’s perspectives are taken into consideration in whatever interventions

have to be made, they feel valued and have a sense of ownership, and would therefore, be

more committed to it. This is in line with the three P’s principle of the UNCRC of 1989,

which advocates for protection, provision and participation.

Children can be protected from the dangers of obesity by providing them with sufficient

information. The third aspect is participation, which according to Shier (2001), based on

Roger Hart’s ladder of participation categorises as listening, supporting, taking the

perspectives into account, involvement in decision-making and finally sharing

responsibility(Don’t understand this sentence). At all these levels, it is the responsibility of

adults to ensure that when children are expressing their views, they must be given careful

attention, be supported with different means of expression and take deliberate measures to be

inclusive at the rest of the levels. When responsible adults act in such a way, they are actually

upholding “the best interest of the child” a paramount principle for the UNCRC to which

many nations are part, including Norway. Parties to the article should ensure that the views of

the children are considered as paramount in relation to age and maturity of the child. Each

level is viewed from different perspectives namely openings, opportunities and obligations.

(Ibid: 110). A sound approach to be more inclusive in considering their views must be to

weigh the benefits and risks involved.

The consideration of children’s welfare both for now and for the future, takes into account the

views they hold towards certain matters that concern them. Obesity is one such case and if

taken as a problem that has to be tackled by adults only, the children may feel that they are

being imposed by the adult ideals and are likely to defy the adult authority and take things

their own way. However, when viewed as active participants in matters that affect their own

lives, and not passive recipients of adult ideals, they become valued members of society who

perceive themselves as agents of change. In our study of gathering children’s thoughts and

feelings, the project recognises them as stakeholders who can make a difference in relation to

the problem through their active participation. This is what is referred to as agency in the

sociology of children. From the Wikipedia, agency refers to the capacity of individuals to act

independently and to make their own free choices. But for this agency to be realized, the

structural factors, including the differential power relations between adults and children, and

how such factors can be enabling or constraining must be considered (? Not sure I get this

sentence either). Shier notes that taking the views of the children into account does not

“imply that every decision must be taken in accordance with the children’s wishes or that

adults are bound to implement whatever children ask for” (Ibid:113). So the views of the

children cannot be implemented and met in entirety but that as decisions are made by the

concerned adults, the views of the children are considered and their best interest upheld. The

project also recognises the extent and limitations of the children competence and therefore

used methods within the limitation of time, which were participant friendly but could still

provide sufficient views on the data required.

4. Results

For simplicity and easy comparison purpose, we categorized our results into questionnaires

and drawing results.

4.1. Questionnaires

In order to investigate childrens attitudes towards physical activity, we have combined some

of the answers of the questionnaires and looked at them in relation to others.

4.1.1. Status of children in term of physical activity

Figure 1 gives an overview of how many children are physically active or inactive during

different parts of the day, based on how they get to school and the activity they involved in

during the breaks at school, and what they do after school.

Figure 1: The overall status of children’s activity level during the day.

Before school School break After school0

2

4

6

8

10

12

14

16

Overall results about childrens physical activity levels

Physically active BoysPhysically active GirlsPhysically inactive BoysPhysically inactive Girls

Parts of the day

No

of ch

ildre

n

As summarised in Figure 1, most of our informants (31 out of 34) were physically active

before school, as they walk or ride bike to get to school. Out of physically active children, 16

were girls and 15 were boys. Most of the children (25 out of which 11 girls and 14 boys)

answered that they were engaged in different physical activities during the school breaks,

including activities such as playing with friends, football, "Sura," "Boksen Går," "everything-

game," swing, murderer, dance, running around, "Hoppetau", walk around, and basketball,

which confirms their physically active status. Some children (9 out of 34), however, said that

they spent the break doing activities that do not involve physical activity, such as sitting still,

thinking and chatting with friends.

31 out of 34 children (16 girls and 15 boys) said they were involved in different physical

activities after school. Figure 2 summarises how the children answered in terms of what kind

of physical activity (organised/unorganised) they were involved in. Accordingly, most of

them (26 out of which 14 girls and 12 boys) answered that they were involved in both

organized and unorganized activities, two girls said that they were involved in organized

activity only, and three boys were involved in unorganized activity only.

Figure 2: Number of children involved in different types of physical activity

Organized only Non-organized only

Both Neither 0

2

4

6

8

10

12

14

Number of children involved in different types of physical activity

Boys Girls

Types of physical activity

No

of ch

ildre

n

Figure 3 depicts something about children’s attitude towards physical activity based on what

kind of physical activity they liked the best.

Figure 3: Number of children who prefer different types of physical activity

Organized only Non-organized only

Both Niether 02468

10121416

Showing what kind of activity the children prefer

Boys Girls

Types of physical activity

No

of ch

ildre

n

27 (14 girls and 13 boys) out of 34 children answered that they prefer to be involved in both

organised and non-organised activities. Three children (2 girls and 1 boy) said that they

prefer to be engaged in organized activity only. Similarly, three children (1 girl and 2 boys)

said that they prefer to be engaged in unorganized activity only. Only one boy expressed that

he would not like to do any physical activity at all.

4.1.2. Frequency of organized physical activity the children do a week.

Here, we asked how many times a week children were doing organised physical activity. The

results are shown in figure 4.

Figure 4: Frequency of organized physical activity the children do a week

Not at all 1-2 days 3-4 days 5-6 days 0

2

4

6

8

10

12

14

How many times a week boys and girls are involved in organized activity

BoysGirls

No of days per week

No

of ch

ildre

n

Out of the total participants 17 children (13 girls and 4 boys), 8 children (4 girls and boys)

and 2 boys said that they do organized physical activities 1-2 days, 3-4 days and 5-6 days per

week. The remaining 7 children (1 girl and 6 boys) picked “not at all” options for how many

times they engaged in organized activity in a week.

4.1.3. Frequency of sitting in front of computer

Here we wanted to know how many days a week children are using a computer or playing

videogames (such as playstation, X-box, Nintendo, etc.). The results from this question are

presented in figure 4.

Figure 4: Showing how many days a week the students are using computers or video games.

Every day 5-6 days a week

3-4 days a week

1-2 days a week

Not at all0

1

2

3

4

5

Number of days children are on computers or play video games

Boys Girls

No of days per week

No

of ch

ildre

n

4.1.4. Attitude towards physical activity

We also wanted to look at children’s attitude towards physical education and if they would

rather like to walk or bike to school. 32 out of 34 children expressed that they liked physical

education and 31 out 34 said they preferred to walk or ride their bicycle to get school, rather

than taking the bus. Figure 5 shows our results from these questions.

Figure 5: Shows children’s attitude towards physical education and walking/biking to school.

Physical education Walking/biking to school02468

1012141618

Children's attitudes towards PE and walking/biking to school

Like: BoysLike: GirlsDislike: BoysDislike: Girls

No

of ch

ildre

n

When giving reasons for liking PE, most of the children that liked physical education stated

that they like it because of things such as “it is fun”, “it involves a lot of sports”, “creates

chance for them get out of class room and work out”, “makes the muscles work”, “enables

one to be more fit and stronger”, “improves body shape and makes them active”. Being quite

good at physical education was also given at a reason for favouring it. Those children who

did not like physical education mentioned the tiresome and exhausting nature of it as the

main justification for their choices.

4.2. Drawing

The students were asked to draw a detailed drawing describing one particular activity they

enjoy doing in their leisure time, physical or not.. 22 of the children drew physical activities

and out of whom 14 were girls and 8 were boys.. More girls than boys chose football as their

motif. On the other hand, no boys chose to draw a handball motif. While two girls did choose

riding and dancing motifs, two boys chose skiing and taekwondo. On the other hand, 12 out

of 34 children preferred to draw other activities that do not involve physical activities such as

computer games (5 children), music lessons (5 children) and other motifs such as objects (2

children). The results of the drawings are summarized in table 2.

Table 2: The activities that the fifth grade students prefer to do during their leisure time

Drawing motifs Gender

Boys Girls Summary

Physical

activities

Football 3 5 8

Handball 0 5 5

Riding 0 2 2

Dancing 0 1 1

Skiing 1 0 1

Tae –kwon -do 1 0 1

Other physical activity

(playing outside related)

3 1 4

Other activities Music lessons, choir,

band

2 3 5

Computer games 5 0 5

Other motifs (book,

picnic)

1 1 2

Summary 16 18 34

5. Discussion

6. Limitations of the study

The main limitations of our study include limitation related to the sample size and

representativeness of the sample, questionnaires, time and absence of direct measurement of

obesity

Small sample size and less representative sample. In this study, 34 (10 years old) children

were included. This is a small sample size, as well as less representative influencing our data

and conclusion as inclusion of more children at different age level will be vital to come up

with a strong evidence about the overall attitudes of children towards physical activity.

Questionnaire: Despite the maximum care taken to simplify the questionnaires to children’s

level of understanding, there were some misunderstanding of some questions and confusions

among children. In addition, some general questions were asked that need to be specified in

order to have a clear picture about the physical activity status of the children. Moreover, the

group faced a lot of difficulties in organizing and analyzing the answers from questionnaires

that might be because of lack expert in statistics in the group.

Time: During data collection, we requested the children to draw whatever they want with the

limited time bound that might affect their thinking or attitudes towards drawing. Thus,

several drawing activities should be done to catch their real attitudes.

Lack of direct measurement of obesity: We were only looking at attitudes, and did not do any

measurements that indicate the weight status of the children. We can therefore not conclude

that a positive attitude leads to less obesity, or that children with negative attitudes were more

obese.

7. Future perspectives

Others studies should be done on childhood obesity taking the limitations of this study into

account. There is a need to educate the people by conducting health awareness programmes

in schools as well as in society about how obesity develops? How it leads to other health

related problems? What are its consequences?

Based on our findings we recommend that designing and implementing new policies that

increase children’s participation in sports should consider children’s attitudes. Similarly,

developing and evaluating obesity treatment and interventions (by the Center of Overweight

& obesity St.Olav Hospital ( RSSO )) should take the attitudes of the children into account.